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Critical Incident Stress Management in Emergencies
Early Psychosocial Intervention Strategies in
DisastersTraining and Development models
by Stuart Stuart
2011
VCC Emergencies Ministry L4,306 Little Collins St Melbourne, Vic 3000 T 9650 4511 F 9650 8383 [email protected] www.vccem.org.au
Victorian Council of Churches
Emergencies Ministry
Table of Contents
Acknowledgements 3
Executive Summary 5
Introduction 8
AIMS OF PROJECT 8
RESEARCH METHOD 9
Training Strategy 10
Training Curriculum - Agency Perspective 11
Billy Graham Evangelistic Association 11
Sharing Hope in Crisis 11
CISM - Individual and Group 11
New York Disaster Interfaith Services 12
Psychological First Aid 12
Disaster Chaplaincy Services - NY 13
CISM 13
Disaster Psychiatry Services - NY 14
Victim Relief Ministries - Phoenix Arizona 14
Stand Alone Training 14
The Salvation Army - New York 15
PFA 15
Baptist Disaster Relief 16
CISM 16
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 1
Recruitment & Retention - analysis 16
Training Curriculum -analysis 17
Emotional Spiritual Care - inclusion and implication 19
US National Strategy 22
NVOAD 22
LVOAD 23
Board Certified Chaplains - what does this mean in practice? 23
Australian Context 23
NCCA sub committee 23
Conclusion 26
Learnings from Research and Investigation 26
Bibliography 28
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 2
AcknowledgementsI would like to take this opportunity to thank
the Emergency Services Foundation for
providing me with the opportunity to
research training and development
programs for the Faith Community in
disasters and emergencies.
I would also like to acknowledge and thank
the following people who contributed to this
report:
• Mr. Jack Munday - Director,
Billy Graham Evangelistic
Association Chaplaincy Service.
• Kevin Ellers, M.Div - is the
Territorial Disaster Services
Coordinator for The Salvation
Army in the U.S.A. Central
Territory.
• Tina Brookes, MSW, Ed.S.
LCSW - is the lead instructor
for Individual Crisis Intervention
and Peer Support, Group Crisis
Intervention, Responding to
School Crises
• Edgar Hatcher - Chaplain
Edgar Hatcher is a Board
Certified Trauma Responder.
• Bill Fogarty – is a Senior
Chaplain with the Charlotte
Division of the Bureau of
Alcohol, Tobacco, Firearms and
Explosives
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 3
Salvation Army Emergency Management HQ, New York
• Andrew Hawkins - serves as
the full time Director of
Operational Chaplains for the
Metropolitan Police Department
in London, England
• Dr. Pierre Julien – is a native
of Haiti who has worked with
Samaritan’s Purse International
Disaster Relief in Haiti since the
January 2010 earthquake.
• Peter Gudaitis - Director, New
York Disaster Interfaith Services
NY.
• Ruth Wegener - Executive
Vice President, New York
Disaster Interfaith Network
• Julie Taylor - Director, Disaster
Chaplaincy Services New York
• John Berglund - Director,
Emergency Services, The
Salvation Army New York.
• Diane Ryan - Director, Mental
Health and Service Programs
Disaster Planning and
Response American Red Cross
in Greater New York.
• Mr. Grant Brenner M.D.
Psychiatrist, New York
• Don & Claire Lopeman -
Arizona Directors, Victim Relief
Ministries Phoenix.
• Dr. Gail Torres - Administrative
Chaplain Maricopa Integrated
Health System Maricopa
Hospital, Phoenix Arizona
• Naomi Paget - Fellow,
American Academy of Experts
in Traumatic Stress, FBI
Chaplain.
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 4
Executive Summary
There has been a strong historical
emphasis among mental health
professionals on the mitigation of Post
Traumatic Stress Disorder (PTSD) in trauma-
affected individuals resulting from natural
disasters. Researchers and practitioners
have developed numerous psychological
tests and methods to identify and treat
those who are likely to develop PTSD.
Included in the repertoire of treatment
methods are Psychological
First Aid, Critical Incident
Stress Management, and
Cognitive Behaviour
Therapy as a continuum of
care.
In practice, many of these
treatment methods are
employed sometime after the disaster has
taken place, usually in and beyond the
identified timeframe of ‘recovery’.
PTSD is only one psychological condition
arising from disasters. Many people
experience a range of emotional, physical,
psychological and spiritual affects, not all of
which will develop into long term conditions.
And few people will progress to PTSD.
Much of what is currently practiced as
Personal Support in the early stages (relief)
of a disaster consists of shelter, food and
water, information and registration. Often,
little consideration is given to the broader
psycho-social-spiritual needs of individuals
on the basis that people are not ready to
process the event and to do so could do
harm. The provision of basic needs is all
that people need!!
When disasters and emergencies strike a
community, emergency managers, as part
of their risk assessment and management
framework must contend with the psycho-
social affect on individuals and
communities. The provision of early
intervention is critical to the long term
psychological, emotional and spiritual
wellbeing of those
affected.
Most people affected
by disasters recover
within the first three
months post event
without any formal
intervention. The focus
on PTSD as well as treatment methods like
CISD has empirical limitations in the
mitigation of long-term mental health
conditions. Many people are affected by the
event and benefit from ‘intensive care’
support regardless of the potential for
ongoing mental health issues.
Psychological First Aid is a useful set of
tools that can be applied by para-
professionals like faith-based volunteer
programs. The benefit of this is the greater
potential for local people to be on the
ground quickly to support affected
individuals.
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 5
Early intervention is important to support the re establishment of belonging for affected communities and individuals. The use of Emotional Spiritual Care techniques and support engages people holistically, does not compartmentalise people’s needs thereby addressing the whole person.
Furthermore, the inclusion of Emotional
Spiritual Care adds value to Psychological
First Aid in that it is inclusive of all other
treatment methods and addresses
questions of meaning that are by nature
spiritual and not psychological. Emotional
Spiritual Care addressed the whole person
and does not
compartmentalize affect
and need. It
understands that there is
a connection between a
person’s need and their
identity. It addressed the
person from the position
of belonging; belonging
to self, to others, to community and to
something bigger than themselves.
The research conducted in the United
States of America assisted in the
understanding of training and development
programs being offered to the faith
community. There are a number of differing
faith based organisations providing training
and development to respond to disasters
and emergencies. Each of these faith based
organisations determine their own needs as
to best practice standards and the type of
curriculum offered.
It is evident that there
is no connection,
collaboration or
coordination
between each of
these faith based
organisations. In fact,
there is a strong
sense of competition
between each of the
major groups.
Furthermore, there are very little
coordination between the States in relation
to a faith based response. Each State
operates independently and the
arrangements with agencies is specific to
that State.
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 6Billy Graham Chapel - Ashville, North Carolina.
Numerous faith based organisations
operate across the States, without coordination, struggle to collaborate and
often in competition with each other.
FBO’s determine their own training
standards and competencies.
The organisation National Volunteer
Organisation Associated with Disaster
(NVOAD) develops policy, process and
guidelines to support a national
understanding of best practice. NVOAD has
a sub committee specifically for the
provision of Emotional Spiritual Care,
however, few FBO’s have signed up to their
guidelines instead preferring to produce
their own.
Disaster response by faith based
organisations seems to based on
geographic strength. In the south, Billy
Graham Evangelistic Association (BGEA),
and the Baptist Disaster Relief organisation
appear to be well represented. However,
The Salvation Army seems to have a greater
national presence and strategy than do
others.
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 7
Introduction
The Victorian Council of Churches (VCC)
Emergencies Ministry programme began in
1977 in response to a major hail storm
affecting the town of Red Cliffs near Mildura.
Since that time there have been many
attempts to grow this program ecumenically,
training both clergy and lay people in
Personal Support Psychological First Aid.
In Victoria, Psychological First Aid (PFA) is
the preferred methodology used by
Personal Support agencies responding to
community crisis. The VCC has developed a
training package which fulfills the Victorian
Department of Human Services
requirements.
There are a number of Chaplaincy training
programmes available in Australia. Many
of these programs, some of which are
attached to tertiary institutions, do not focus
on the specific nature of disaster, trauma
and community response. Others attempt
to include materials which go beyond the
specific issue of civilian trauma in disaster.
The VCC remains committed to training only
that which is purposeful to the role and
function that the company is funded to
perform.
Having the opportunity to research methods
which have been used and tested post
September 11 and Hurricane Katrina would
be invaluable to our programme in
Victoria.
AIMS OF PROJECT
a) Examine training packages offered in the
United States in relation to the faith
communities response to disasters
including
i. With particular reference to
comparing CISM & PFA
ii. Which faith based organisations
are leading the field in this training
and why?
iii. Other relevant material that
should be included in the training
package?
b) Discover ways of building cooperation
between the faith traditions within the
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 8
Suffering is not what destroys people, rather “suffering without
meaning” (Victor Frankl)
emergency environment with respect to
training, including.
i. Methods used to involve clergy
and laity in training?
ii. What are the blocks for faith
traditions attending this kind of
training?
c) Understand the training implications for
faith based disaster organisations and
government authorities.
i. With respect to curriculum
ii. With respect to endorsement of
programmes and training
packages
iii. What are the interstate
arrangements across the United
States of America (is there a
national training strategy?)
RESEARCH METHOD
The research conducted involved face to
face interviews with people in specific and
relevant fields of disaster chaplaincy
services.
Sixteen interviews were conducted in
numerous States, Counties and
jurisdictions . Those interviewed also
represented many different agencies across
the United States.
The interviews addressed specific questions
related to training and development of faith
based volunteers responding to
emergencies and disasters. The information
gained also pertained to the level of
integration of training programs and whether
a national strategy exists in the training of
faith based organisations.
This required travelling to North Carolina,
New York, and Phoenix, Arizona to interview
all relevant stakeholders in the training of
different faith communities.
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 9
Ground Zero - World Trade Centre Site
Training Strategy
The first task was to determine who was
facilitating training together with what that
agency believes to be essential to effectively
support disaster trauma affected individuals
and communities.
A number of faith based agencies have
entered the post disaster support space,
especially since September 11 attacks on
the World Trade Centre and Hurricane
Katrina. In order to establish themselves as
a legitimate resource, each agency has
developed their own training program and in
some cases curriculum, others have used
the International Critical Incident Stress
Foundation modules.
Most of these faith based agencies have
determined the type of training based on
generic psycho-social support models with
the addition of spiritual care.
Prior to the late 1990’s very little had been
written about spiritual care in the health care
field. Much of the material was specific to
religious groups or organisations and was
challenged as to its efficacy when applied
outside of those contexts. Anecdotally, it
was said that the provision of spiritual care
had benefits to those experiencing some
form of traumatic response to an event, but
had not been substantiated through
research.
Each faith based agency had there own
idea of what spiritual care might look like
and this proves to be problematic when
attempting to implement this into the
broader personal support environment.
Since the September 11 attacks and
Hurricane Katrina, there has been a
significant amount of research conducted
into the provision of Emotional Spiritual Care
in a broader community based response to
emergencies and disasters.
Much of what is being provided by faith
based organisations is still generic psycho-
social support as determined by the mental
health sector. With the addition of some
spiritual care practices.
There is a determined effort by these faith
based organisations to establish credibility
in the disaster recovery environment
through training volunteers in identified and
approved mental health practices.
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 10
BGEA Training Centre - Ashville, North Carolina
Training Curriculum - Agency Perspective
Billy Graham Evangelistic Association
The Billy Graham Evangelistic Association
(BGEA) Rapid Response Chaplaincy
program has been operational since the
September 11 attack on the World Trade
Centre (known as 9/11).
A staff member of BGEA went into the
secure zone of the 9/11 site, gained
permission to establish a support network
for affected people, and began providing
emotional and spiritual support to those on
site and off site.
Much of this was done with little or no
training and experience, and as a result
many lessons were learnt.
BGEA RRT Chaplaincy program Director,
Jack Munday, established a training
program that included a number of
BGEA Director, Jack Munday & Stuart
elements to support affected community
members.
Sharing Hope in Crisis
The Sharing Hope in Crisis seminars are
specifically designed according the ethos,
philosophy and theological base of BGEA. It
incorporates both generic care principles
whilst incorporating specific religious
practices.
Seminar topics include:
• When Crisis Happens
• The Good News
• Good Communication
• What to Say; What to Do
This program is designed for faith
communities to use within the particular
religious community. It has language and
practices that is unlikely to translate into the
broader community context - especially
here in Australia.
CISM - Individual and Group
Critical Incident Stress Management (CISM)
principles have been practiced since the
early 1980’s when Jeffery Mitchell first came
up with his theory.
BGEA offer CISM as a Registered Training
Organisation for the International Critical
Incident Stress Management Foundation.
They have train the trainers who provide two
main programs:
• CISM - Individuals - where trainees learn
how to provide Critical Incident Stress
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 11
Management techniques on individually
affected persons.
• CISM - Group - where trainees learn to
provide Critical Incident Stress
Management techniques to homogenous
groups affected by traumatic events.
Trainees who complete these courses will
be accredited by the ICISF and certified to
practice according to the principles in the
training sessions.
During my stay at Ashville, I participated in
the training on Emotional Spiritual Care
which was facilitated by Mr Kevin Ellers who
is the Territorial Disaster Services
Coordinator for The Salvation Army in the
U.S.A. Central Territory. Mr Ellers is a highly
skilled practitioner in disaster management.
He responded directly to 9/11 and
Hurricane Katrina.
Kevin is also the Chair of the Emotional
Spiritual Care (ESC) sub committee for
NVOAD. He assisted in the development of
the national guidelines for the delivery of
ESC.
The training, over two days, gave a very
clear indication as to what Emotional
Spiritual Care is and is not. There were
ample opportunities for groups discussion
and feedback to the main group.
New York Disaster Interfaith Services
Psychological First Aid
New York Disaster Interfaith Services
(NYDIS) chooses to use a model, which was
first introduced into the mental health
environment for supporting trauma affected
people in the 1950’s. This model is known
as Psychological First Aid (PFA).
PFA uses seven basic principles that do not
require the user to be proficient in the use of
psychological interventions or be a qualified
therapist.
The material is delivered in a classroom style
environment.
During my stay in New York, Executive
Director of NDIN, Ruth Wegner provided
one on one training taking me through the
manual and giving me opportunity to
examine the similarities and differences
between the model used by VCC EM and
NDIN.
NYDIS Director, Peter Gudaitis & Stuart Stuart
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 12
Through the discussion, Wegner states that
there is a great difference between process
or model and meaning making in the
training and delivery of service. She goes on
to say that “PFA is a process that enables
the opportunity for story telling and to allow
the affected person to develop meaning in
the light of the trauma.” It has to be their
meaning not our meaning that supports
positive recovery.
Disaster Chaplaincy Services - NY
CISM
Disaster Chaplaincy Services New York is a
“501 (c)(3) nonprofit, nonsectarian
organization whose purpose is to assure
skilled and appropriate interdisciplinary
spiritual care for all people affected by
disasters in the New York tri-state area. We
do this by recruiting, screening, orienting,
training, educating, deploying and
DCS Director, Julie Taylor & Stuart Stuart
supervising chaplains on behalf of the
religious communities of the tri-state
region.”
Disaster Chaplaincy Services (DCS) is a pre
9/11 organisation. It originated primarily to
respond to airline incidents in New York.
Every 18 months, there was an airline
incident. The Federal Aviation Act 1996
determines what kind of care is provided to
mass casualty events involving airlines. It
determines that there needed to be
regulation and coordination in the way
people of mass casualty events are cared
for.
DCS initiated an internal training module
which looked at standard operating
procedures and self care guidelines. In the
last two years, DCS has decided to increase
the level of training required to include the
CISM material as outlined by the ICISMF.
Rev Julie Taylor is a qualified trainer able to
deliver the CISM course. Included in this
package is Individual Crisis Intervention,
Group Crisis Intervention, Emotional
Spiritual Care and Pastoral Crisis
Intervention among others.
DCS believes that the Pastoral Crisis
Intervention module will become the
baseline standard for basic training.
It has to be understood that most Chaplains
who volunteer with DCS also come with
previous skills and experience including
Clinical Pastoral Education (CPE).
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 13
The minimum qualification to be a volunteer
Chaplain is a high school diploma and
whatever the denomination requires for
approval to be a minister.
Disaster Psychiatry Services - NY
Mr. Grant Brenner M.D.
I was fortunate to be able to spend time
with Mr. Grant Brenner who was the editor
and lead on the writing of the book
“Creating Spiritual and Psychological
Resilience - Integrating care in disaster relief
work”. This book brought together people
from all disaster relief, mental heath and
religious disciplines to collaborate on the
writing on how to effectively work together
to support people post disaster.
Brenner established an organisation called
Disaster Psychiatry Outreach and
developed an interdisciplinary conference.
Brenner stated that whilst he is not a
religious or spiritual practitioner himself, in
his clinical practice he accepts and
acknowledges that some people find
spirituality important as part of their
recovery.
The discussion quickly turned to the need to
train disaster practitioners, volunteers in
how to look after themselves, to recognise
the signs of fatigue, stress and burn out and
methods to effectively manage those
manifestations. Julie Taylor (DCS) indicated
that 66% of clergy who attended 9/11 had
developed some form of Post Traumatic
Stress and 33% are no longer in ministry.
This is also the case in New Orleans and
supporting Brenner’s statement for specific
self care training.
This information has to be understood in the
context that prior to 9/11 training was not a
high priority for faith based groups
responding to disaster events. It is now
seen as essential.
In relation to CISM, Brenner suggests that
the application of CISM to all people
affected by disaster can be unhelpful and
even harmful.
Victim Relief Ministries - Phoenix Arizona
Stand Alone Training
The VRM training module is stand alone and
specific to the agency. VRM began in 1999
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 14
through Mr Gene Grounds who is located in
Dallas, Texas. He believes that “there are
many victim service organisations, but very
few responded as ambassadors to the
Lord.” It is clearly based on strong
evangelical Christian principles and refers to
biblical examples of care throughout the
training.
The mission of VRM is to “mobilise the faith
community to partner with law enforcement
agencies, victim service organisations and
homeland security to deliver appropriate
physical, emotional, and spiritual support to
victims of crime, disaster and terrorism.”
The curriculum addresses information
pertaining to grief and loss as well as some
trauma related materials.
It then moves into the role of Chaplain and
working within the Incident Command
System.
Finally, there is a chapter on self care.
The material, unlike all other providers of
Emotional Spiritual Care is not connected to
a universally recognised psychosocial
recovery model, except for the short
introduction to grief and loss. The use of the
term victim is quite confronting and sharp
and there are probably better ways to
identify these people. Perhaps the term
affected person might be better suited as
this does not fix a person in one
psychological space known as ‘victim’.
The Salvation Army - New York
PFA
John Berglund, Director Emergency
Disaster Services.
The Salvation Army uses Psychological First
Aid as the primary skill set required for
volunteers responding to disasters.
Berglund states that the primary skill set
should relate to three primary questions;
How far can I take this? What are the signs?
When do I refer?
Berglund said that they tried to introduce a
greater level of training requirement and
standards, but they found the capacity
issues increased with fewer people
volunteering to do the training. He went on
to say that exercising these new skills
regularly and maintaining skill is another
complexity to add to the mix.
He went on to say that The Salvation Army
has been undertaking training for the past
seven years costing the organisation
millions of dollars, and it largely failed due to
the inability to keep people skilled for an
event that may never eventuate. He went on
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 15
to say that a limitation with the CISM
training is that a person who participates in
13 contact hours is not really certified, they
participated in 13 hours of information
dissemination. If this material is not used
regularly it becomes irrelevant.
Berglund states that the essential needs for
anyone responding to disasters should be,
how do I take care of myself, and when am I
out of my league - when do I refer.
Baptist Disaster Relief
CISM
Mrs Naomi Paget is the author of the Baptist Disaster Relief handbook which is used to train all volunteers through the Baptist Church of America.
Naomi is a Federal Bureau of Investigation (FBI) certified Chaplain and senior trainer for the International Critical Incident Stress Management Foundation (ICISMF) and primary trainer for Baptist Disaster Relief.
Baptist Disaster Relief use CISM a the basis for their training. The training is conducted according to the prescribed method set out by ICISMF and is accredited with the same.
During my visit to interview Mrs Paget, I participated in a four day CISM Group training program facilitated by Mrs Paget.
The training course, materials and presentation are almost identical to the way in which it is delivered in Australia and through Critical Incident Management Australia (CIMA).
Recruitment & Retention - analysis
Recruitment and retention are challenges for all volunteer based organisations. Volunteers by nature are people who share their time between many activities in their life. Volunteers unlike paid staff are also able to say that they are unavailable for an activity at certain times.
Many of the people interviewed indicated that recruiting of volunteers through the faith community was not too difficult. The faith community has a large resource in people, most of whom follow the values of the Christian tradition which includes ‘loving thy neighbour’. The challenge is to determine the suitability of those people as well as having an effective process that managed people who did not have the skills or attitude for the kind of work required.
Volunteer organisations including those from a faith base attract people from varying backgrounds. The motivation for wanting to respond to disasters is not always well intended. Establishing a mechanism to effectively screen candidates and eliminating people who do not fill the relevant criteria is essential.
The Victorian Council of Churches Emergencies Ministry has a number of
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 16
required processes for trainees to attend to before getting to the training. It is a requirement that volunteers wanting to join the VCC EM are nominated by their faith leader - with the assumption that they will vet applicants and deny inappropriate people from applying. It is also a requirement that applicants have a current National Police Check and Working With Children’s Check.
At present the program is working on a mechanism to evaluate participants in training across a number of measures in order to eliminate people before they are issued with a certificate and identification.
Training Curriculum -analysis
Critical Incident Stress Management (CISM) has been around since the 1980’s. CISM includes a range of treatment methods such as de briefing, de fusion and demobilization.
Jeffrey Mitchell, a former firefighter and paramedic, having obtained a Ph.D. in human development, believed that there was a consistency between combat stress and the stress of emergency service personnel.
Critical Incident Stress De briefing (CISD) is designed to address the psychological needs of a person who has experienced a traumatic event. Originally designed for emergency service personnel, it was deemed useful for primary victims as well (McNally, Bryant, Ehlers 2003 p 56).
CISD has seven phases, the introduction, fact phase, thought phase, reaction phase, symptoms phase, teaching phase, and
reentry phase. Each phase is designed to help the affected person to explore different, yet sequential elements of the stress reaction, piecing together the event and involving others in the development of a bigger picture of what has taken place.
Debate has raged for many years as to the efficacy of CISD in a civilian context. Originally, Mitchell asserted that formal CISD should be mandatory for all personnel involved in responding to an event (McNally ibid p 57 & Choe 2005 p 71). This was because of the fundamental view that all people involved in responding to an event were impacted psychologically and that CISD would help them in their recovery and performance in future responses. Police departments in the United Kingdom (UK), some banks in the UK and Australia as well as other industries have made CISD compulsory after a Critical Incident has occurred and have made this a standard of care.
The question remains, does CISD actually prevent the likelihood of a trauma affected civilian going on to develop a diagnosable mental health condition or PTSD?
There are many cases where people have supported the process of CISD as being helpful. However, this does not equate to the reduction in PTSD. Random Control Trials (RCT’s) are a standard method for testing the efficacy of any intervention, psychological or pharmacological (McNally ibid p 58). Tests are administered to determine whether the method used provides a better outcome for the individual or group and therefore can be generalised across the population. A challenge for the development of RCT’s for CISM is that as part of the testing regime, a control group
VCC Emergencies Ministry
Critical Incident Stress Management in Emergencies - The Inclusion of Emotional Spiritual Care 17
needs to be established for those being treated. This of course raises ethical issues for researchers (McNally ibid p 58). Governments will not fund studies that intentionally traumatize people to measure reactions and results from differing intervention strategies – of which one group in the trial would receive no support.
There are RCT’s that have both supported and disputed the efficacy of CISD in its application in the reduction of PTSD in persons treated.
What is clear is that there is no ‘one size fits all’ approach to trauma recovery; it’s a matter that some practices are less harmful than others. Inappropriate interventions may not only be unhelpful but may impede natural recovery processes (Choe ibid p 73 & Davidson et al 2006 p 9).
After significant research into multiple session early interventions for the treatment of post traumatic stress disorder, Kitchiner, Kenardy & Bisson (2010) state “The lack of evidence for the efficacy of single session individual debriefing has therefore led many experts in the field to caution against its use.” They go on to say that there is no recommended routine intervention strategy for the treatment of individuals exposed to trauma and doing so may have an adverse effect on some.
CISD has been applied across a range of traumatic events with varying outcomes. Variables exist in the data when generalizing efficacy of CISD across differing traumatic situations. First responders have a different perspective on CISD than do the civilian population. People’s exposure to differing events like motor vehicle accidents, shootings and natural disasters vary and so
the treatment process should reflect the person’s needs. McNally et al (2003) state unequivocally “there is no convincing evidence that CISD reduces the incidence of PTSD.”
Psychological First Aid (PFA) is a systematic set of actions to help people in the early stages of a disaster cope with the their exposure to trauma. The eight core actions of PFA are contact and engagement, safety and comfort, stabilization, information gathering, practical assistance, connection with social supports, information on coping support, and linkage with collaborative services (Ruzek et al, 2007 p17). An international expert panel for use at mass casualty events endorsed it because it is composed of empirically defensible interventions, which are unlikely to be harmful (Young 2010, p134). PFA was first introduced in the 1950’s by Drayer, Cameron, Woodward and Glass for the American Psychiatric Association, at the request of the U.S. Federal Civil Defense Administration. They were requested to provide guidance on the management of the aftermath of community disasters (Forbes et al 2011 p226).
Department of Mental Health and Substance Dependence WHO (2003) suggests that most acute mental health problems during the acute emergency phase should be addressed using the principles of psychological first aid (p4). This is supported by Boscarino et al 2005 in Everly et al 2010 who quote that a disaster mental health study focusing on the 9/11 terror attacks on the World Trade Centre found that early brief intervention at the site was the most effective post disaster treatment. Also, Young (2006 p134) identifies the benefits of PFA if delivered
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within the first four weeks of a disaster to individuals who are experiencing acute stress reactions or appear at risk for being unable to regain sufficient functional equilibrium by themselves.
Gordon (2007) extends the PFA process slightly by encouraging affected persons to dialogue about their experience at their pace and depth. He argues that if trauma affected people only have one image of the event and their experience of the event, then there is only one meaning to that event. By providing a safe space to process the images and experience, an alternate meaning can be formulated which can be helpful to healing. To do nothing actually enables a trauma-affected person to remain in heightened arousal, which can be harmful long term.
Therefore, intentionally intervening at the earliest stage of a disaster event, using PFA principles, provides a greater potential for a positive psychological outcome.
PFA is consistent with other treatment methods like CISD and is an extension of the five principles of Crisis Intervention, while building on an action plan of recovery (Everly 2010 p 3).
As a treatment method, psychological first aid is relatively safe in the hands of appropriately trained people. This intervention is capable of being delivered by para-professionals such as the faith community and their leaders.
In 2008, providers supporting affected people after Hurricane Gustav and Ike undertook a survey of their perceptions of PFA. Overall, providers concluded that there were many benefits to the use of PFA with affected people who indicated their
satisfaction with the level of support offered (Allen et al 2010 p512).
It is recognised within the PFA principles that a person has more than simply a pathological condition. It recognizes that people have basic needs that if met, can build on a persons own resilience. It however, avoids the deeper constructs of meaning of which the addition of Emotional Spiritual Care can support.
Emotional Spiritual Care - inclusion and implication
The Emergency Management Manual of Victoria identifies four pillars requiring strategic thinking in a disaster. One of those pillars is Social and Community. Identified within the Social and Community pillar are a number of elements requiring support. It identifies the physical, emotional, psychological, financial…and spiritual (emphasis added). However, in no other government document is this referred to or defined.
In 2011, the Department of Human Services (DHS) was approached by the State Manager of the Victorian Council of Churches Emergencies Ministry and asked if a definition could be sought. DHS asked the VCC to draft a definition to be added to the Emergency Relief Handbook 2011.
The current definition for Emotional Spiritual Care is;
Emotional Spiritual Care roles
Emotional spiritual care roles are provided by qualified and experienced faith-based
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volunteers, and are concerned with the ultimate search for meaning in times of crisis.
Emotional spiritual care is inclusive of psychological first aid principles and skills. It utilises psychological, spiritual and theological resources to aid persons in psychological and/or spiritual distress, while taking careful account of cultural and faith diversity.
In the early stages of an emergency, emotional spiritual care roles can include:
• intentional creation of safe and calm spaces to aid in the emotional and spiritual processing of the event
• grief and loss support
• support with religious and spiritual rituals.
(Department of Human Services (2011 p 17).
Nolan (2005 p73) states that some of the most enthusiastic supporters of faith-based international aid claim that the religious orientation of FBO workers gives them a more holistic approach to helping as they are aware of the spiritual as well as material needs of those whom they serve.
The American Red Cross (ARC) defines spirituality as “each persons ways of finding meaning in his or her life experiences in light of a relationship to themselves, their community, and the transcendent.” Therefore spiritual care is a sustaining care that draws upon a person’s own inner religious or spiritual resources (Sutton 2003 p 420).
The ARC defines itself as a “humanitarian organisation providing relief to victims of disasters”. It operates as an independent organisation and provides a service to all persons regardless of race, culture, religion
or gender. By this definition and mandate, the ARC and by implication all Red Cross organisations, are unable to specifically provide spiritual care to those who may benefit. Therefore Red Cross agencies must access external resources to ensure the adequate provision of care if being provided (Sutton p 416).
As an example of the kind of partnership that can be established are the Spiritual Aviation Incident Response (SIAR) teams, which are coordinated through the ARC along with an advisory team of professional chaplain groups. These teams are deployed with ARC to all Aviation incidents in the United States.
A partnership of this kind would be beneficial to affected people in Australia, however the Australian Red Cross seem reluctant to engage with faith based organisations in the provision of spiritual care.
The extension of care beyond purely psychological and emotional to include the spiritual is a significant step.
However, what must also be taken into consideration are the cultural issues in Australia. Emotional Spiritual Care is a relatively new concept in Australian emergency management, especially when supporting civilian communities. Not everyone is going to be supportive of the use of Christian ministers and church people in this context. The diversity of belief systems in Australia, including those who profess to have no belief, means that Christian Chaplains must provide support to the community in a way that is not proselytising or with the sole purpose of converting people to their faith tradition.
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The community and government expect helpers to have skills that have been tested and proved to be successful in order to help those affected by trauma. Particular concerns might include the skills and abilities of faith members working in this field, and what, if any, agenda might they be coming with?
Hugh Mackay is a psychologist, social researcher and novelist. In Frame’s article (2010 p 103), relating to religious connection in Australia, Mackay states, ‘To put it mildly, Australians are easygoing about religion. Among non-churchgoers, the prevailing attitude is closer to indifference than skepticism. They are suspicious of extremists, generally benign in their attitude to the church and its influence in the community, though some associate any form of religion with oppression, conformism and bigotry. While they may connect their desire for greater clarity of purpose with a vague desire for religious belief, they seem content to stick with a relatively unformed idea of ‘God’. They are rather embarrassed about discussing it’
According to the Australian Bureau of Statistics, in the 2006 Census, 20,061,651 people completed and returned the Census form.
Of the 20,061,651 respondants, 13,213,637 people identified themselves with a religious or spiritual group. This equates to 65.8% of the total population in Australia, therefore justifying an appropriate emergency management response for this and other groups.
Indeed, the importance of including faith-based organizations in the response to emergencies and disasters is essential to
building community resilience and supporting individual wellbeing.
Immediate reactions to trauma challenge an individuals world-view and meaning. This is not a purely psychological function, rather a deeper spiritual questioning and search for understanding. Cadell et al (2003) in Vis (2008) found that spirituality is part of meaning making and coping and contributes to post traumatic growth. Mattis (2002) in Vis (2008 p71) confirmed a relationship between religiosity/spirituality, meaning, and interpretations in coping during times of adversity.
The American Red Cross conducted a survey of affected people in the immediate aftermath of the 2001 World Trade Centre attack. More than 80% of those surveyed said that they would walk past a social worker/psychologist and government bureaucrat in preference for a chaplain (or spiritual carer) to seek support and comfort. Roberts et al 2008 p xi).
The provision of Emotional Spiritual Care means that each person’s need is addressed individually and is inclusive of all current support practices including the spiritual dimension. To do nothing, meaning to not support people affected by trauma could increase the likelihood of an increased development of mental and spiritual health problems.
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US National StrategyNVOAD
National Voluntary Organizations Active in Disaster (VOAD) was founded in 1970 in response to the challenges many disaster organizations experienced following Hurricane Camille, which hit the Gulf Coast in August, 1969.
Prior to the founding of National VOAD, numerous organizations served disaster victims independently of one another. These included both government and the private, nonprofit sector.
As a result, help came to the disaster victim haphazardly as various organizations assisted in specific ways. Unnecessary duplication of effort often occurred, while at the same time, other needs were not met. People who wanted to volunteer to help their neighbors affected by disaster were often frustrated by the variety of organizations in some areas of service and the total lack of opportunities to serve other needs. Further, there was only limited availability of training for potential volunteers. Information for victims on services during disasters was woefully inadequate. Likewise, communication among voluntary disaster agencies was very limited and coordination of services was negligible. In fact, mechanisms for this were non-existent.
The seven founding organizations came together and committed to fostering the four C’s—communication, coordination, collaboration, and cooperation in order to better serve people impacted by disasters.
Today, National VOAD is a leader and voice for the nonprofit organizations and volunteers that work in all phases of disaster—preparedness, response, relief, recovery, and mitigation. National VOAD is the primary point of contact for voluntary organization in the National Response Coordination Center (at FEMA headquarters) and is a signatory to the National Response Plan.
A sub committee of NVOAD is the Emotional Spiritual Care committee which works to develop collaborative working relationships with many faith based organisations responding to emergencies and disasters. It also works to build guidelines to support the work of Emotional Spiritual Care.
Despite efforts by NVOAD and the ESC sub committee, many faith based organisations have not and will not sign up to be a member. Moreover, it has been very difficult for the ESC committee to get faith based organisations to implement the guidelines established by this committee. Many FBO’s simply want to operate through local relationships and operate independently of any national guidelines.
This means that, particularly in the south, fundamental, evangelical groups walk into emergency and disaster sites and do what they like often without coordination and integration into local emergency management systems of structures.
The level of independence these FBO’s demand is such that it is extremely difficult to get any agreement on how FBO’s should operate in emergencies.
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LVOAD
LVOAD is the local form of NVOAD. Its role is to coordinate local NGO’s response to emergencies or disasters.
Board Certified Chaplains - what does this mean in practice?
Board Certified Chaplains (BCC) are often perceived to be the preferred group to call on in a disaster. Many BCC’s originate from the hospital system and have completed numerous courses to enable themselves to be called Board Certified.
The American Red Cross in New York City will often only use BCC’s to provide Emotional Spiritual Care to affected persons in Evacuation Centres.
There are a number of challenges for the American emergency management system in utilising BCC’s.
Firstly, there are many certifying bodies, each with their own criteria as to what is required to become a BCC. The Catholic Archdiocese of America is a certifying body for Catholic Chaplains, there are Police, EMT and Fire certifications for Chaplains as well as many other denominational certifications.
Some certifying bodies require significant training in areas like pastoral care and psychology whilst others are less stringent.
There is no standard by which Chaplains are certified, nor often are there ongoing evaluations of these certifications.
A further complication as i observed, was that very few people become a certified
chaplain, partly because of the initial onerous training and registration requirements. Whilst this might appear to screen out those who are not committed to the process, the effect is that you have very few people to draw on in a mass casualty event thus only working to create a capacity issue. For example, during the 9/11 event, thousands of Chaplains and faith based organisations provided support to affected people. If only BCC’s were used, there would only be a handful of people available in New York City and limited supply nationally.
You do not need to be a Board Certified Chaplain to be an effective carer of disaster affected people. You need a skills set for the task, understanding of the role and operational boundaries which will enable you to refer affected people onto the relevant organisations. Board Certification can limit operational capacity and sometimes set up unnecessary competition between personnel.
Austral ian Context
NCCA sub committee
Since arriving back to Australia, I have had the opportunity to speak with the General Secretary of the National Council of Churches about developing a national strategy for FBO’s response to emergencies or disasters.
It was agreed to establish a sub committee to explore standards, guidelines and even a national chaplaincy model.
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A preliminary paper was written out of discussion between Stephen Robinson (Coordinator of the NSW Disaster Recovery Chaplaincy Network) and Stuart Stuart (State Manager of VCC’s Emergency Ministries).
This conversation arose from the recognition of the need for a national approach to ecumenical disaster recovery chaplaincy in Australia. At present only NSW and Victoria have disaster recovery chaplaincy factored into their recovery plans. It is recognised that now is an important time to learn from both these chaplaincy networks and create from their experience a standard of training and practice which can be implemented nationally.
This would involve connecting with government at both federal and state levels, and with the state’s ecumenical councils to begin dialogue.
From our experience at working with Governments the things most needed for acceptance of such proposals are:
Unity – Where a proposal comes from a wide group of representative churches without dissent. This is particularly helpful where there is a large ecumenical council such as VCC or NCCA backing a proposal.
Clarity – Where a proposal is well thought through, well expressed and easily understood.
Relevance – Where a proposal is clearly able to meet a present need, add capacity to welfare response.
Uniformity – Works in concert with existing arrangements and community partners.
Affordability – Economics are very important. Governments need to meet budgetary commitments and are loath to commit to any new thing that carries a cost impost.
What has been developed in Victoria and NSW in terms of training, organisation and philosophy is highly compatible. The suggestion is that training, recruitment and standards of disaster recovery chaplaincy should be adopted from these networks.
Each state manages its own framework of disaster welfare response through unique arrangements, so we are envisaging in this paper an overview of what a ‘generic’ chaplaincy program might look like. This could be easily factored into virtually any setting in the remaining states. This paper seeks to address some key issues that need to be addressed before bringing a submission to other ecumenical councils or governments.1
Members of the committee, as part of the development of the strategic plan, contacted the Attorney General’s Department - Emergency Management Australia to discuss current policy in relation to inclusion of faith based groups responding to emergencies or disasters. This conversation was with the view to developing a national agreement or national plan involving volunteers from faith based organisations in a coordinated and integrated manner. EMA indicated that these arrangements needed to take place at a State or Territory level.
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1 Taken from original proposal to National Council of Churches 2012.
The National Council of Churches of Australia executive have endorsed the proposal, including strategic plan and training curriculum as a model which could be utilised by State or Territory faith organisations.
Many people from across Australia have travelled to Melbourne to train under the VCC Emergencies Ministry training program with the view of taking the model back to their own State for consideration and negotiation.
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Maricopa Hospital, Phoenix, Arizona
Conclusion
The training and development of faith based organisations in the United States of America highly valued by agency and volunteer alike. Each agency or program appears to have a strong understanding of the need for personnel to be trained to respond to emergencies and disasters and to be appropriately skilled for the task.
Understanding of curriculum that is best suited to the kind of response being offered is questionable. For example, most faith based organisations that I attended use the International Critical Incident Stress Foundation modules of Critical Incident Stress Management (CISM) for Individuals and Groups, along with Emotional Spiritual Care. These course providing a framework for supporting affected people, however, it may not produce evidence of general post traumatic growth or positive psychosocial recovery.
Psychological First Aid is used by both New York Disaster Interfaith Services (NYDIS) and The Salvation Army - New York Division. It is accepted by these organisations to be useful in supporting trauma affected people and is less complex to teach and less expensive, therefore making it accessible to more volunteers.
There is a distinct lack of cooperation and coordination between the agencies across the country, and in some cases it could be argues that there is strong competition for space.
There has been a lack of connection with governing agencies like NVOAD, FEMA and
the American Red Cross. This has and continues to improve over the last five years especially as FBO’s become more familiar with arrangements, structures and systems.
Most of the training is connected to the International Critical Incident Stress Foundation (ICISF) and is seen to be the panacea for training of volunteers.
Learnings from Research and Investigation
• The USA does not have a national strategy when it comes to the coordination and integration of volunteers from the faith based community. The NVOAD Emotional Spiritual Care Sub Committee attempts to develop best practice guidelines for faith communities to adopt, however few organisations have agreed to the ESC guidelines.
• Curriculum is dependent on the agency delivering the service. Many agencies choose the ICISF program because it provides an accreditation and is structured in such a way that is relatively easy to deliver. The challenge in research has to do with its efficacy when applied broadly to all disaster affected persons.
• There is no standard of care - apart from the axiom “do no harm”, there is little research on what constitutes harm.
• Implementing a national strategy for training and development would be less challenging in Australia due the size of the country and current lack of structure for
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the faith communities. Having the NCCA support the proposal as outlined by Stephen Robertson and myself means that other faith based agencies have a template from which to work from. The initial negotiations with the Attorney General’s Department has also provided an opportunity to continue to grow relationships with emergency management agencies.
• The VCC Emergencies Ministry has a strong and robust strategic plan for training and development that incorporates all the necessary elements required to train volunteers from the faith community.
• The VCC Emergencies Ministry has a strong program that is coordinated and integrated into existing government emergency management arrangements.
• The connection and influence of VCC Emergencies Ministry with NCCA nationally and DHS and Local Government within Victoria is strong.
• PFA is a well suited training curriculum for the function the agency performs in emergencies.
• The addition of Emotional Spiritual Care to the continuum of care is an important and distinctive feature.
• That the generic roll out of CISM can be unhelpful to some affected people.
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